Improvement Stories

Contributor:Sharon Dalrymple RN, BN, MEd, LCCE, FACCEClinical Nurse EducatorHigh River Hospital Community Maternity Program CNECommunity Maternity Unit, High River Hospital, High River Alberta

What did you set out to change or improve?Our intention was to provide our OB patients with the knowledge needed to make appropriate decisions for epidural use during labor. We educate our patients on the risks, effects on the obstetrical care, and alternatives for pain management during labor.

How did you change it? What new policy, process, or practice did you put in place?Delayed cord clamping for at least one minute in healthy newborns and selected premature babies is preferable, as stated by NRP. (Addendum to the NRP provider textbook, 6th edition, 2011). The benefits, according to the literature, afford babies the best of both worlds: a.) optimal red blood cells for oxygen carrying capacity, and b.) the least amount of immature red blood cells to cause jaundice risk. Our program had adopted the recommended delayed cord clamping practice for vaginal births, but not for cesarean section births. The OB’s wanted to have the delayed cord clamping practice extended to the C/S patients as well, when appropriate.

Who was involved in making the change and what was each person’s role?Our Maternity Core Team (multiprofessional OB practice group) discussed the issue and decided to adopt the delayed cord clamping practice in the OR. Discussion took place with all of the stakeholders about this change to practice: the OR nurses and anesthetists, the Maternity Unit RN’s, and childbirth educators (to the extent possible).

The key process areas to note were that:

the timer on the OR baby warmer would be started when the OB stated that the baby was born,

the baby would be assessed, dried off and stimulated with the OR gauze sponges available,

at one minute according to the timer, the Baby Nurse would notify the OB,

the OB would then clamp and cut the cord and bring the baby to the warmer.

Who was involved in making the change and what was each person’s role?We started out with changing the practice for all of our booked (elective) cesarean section families. This provided a more controlled environment to begin the change. All of the players were involved: the OR nurses, the OB’s, assistants, anesthetists, baby nurses and doctors and each case staff set was informed of the new practice, as well as the parents. The OBs would mention the new practice in their pre-op visit, either on the day of surgery, just before the surgery, or ahead of time at the consult visit.

The practice quickly extended to the other non-elective cases, and as assessed “appropriate”, delayed cord clamping was done for them as well.

Presently, in our facility, the practice of delayed cord clamping is considered for ALL of our patients, both vaginal and cesarean birth.

How did you determine if the change worked? What data did you collect? How did you define “success”? How did you ensure your change did not have any unintended negative effects or consequences?In this situation, we wanted to change our practice across the board to match the recommended guidelines. That part was achieved rather quickly and completely, as we are a smaller facility and have very good effective working relations amongst all team members. We collected the same data as before and charted more by exception to the delayed cord clamping practice, and stated why the process was not done. In that respect, we were successful.

We also set in an audit process, through our “No Harm Committee”, (a group that evaluates various practice and program components) to make sure that we are doing right by our patients and families.

That is when we discovered an unintended negative effect on some of our babies. Through our No Harm Committee, over the space of eight months, we ended up with three babies postpartum after booked sections, whose blood sugars and glucose levels were worrisome. These three babies had a hard time achieving steady levels of glucose over about 2.5 days after their births. All three babies were also SGA (small for gestational age).

When we looked at the initial and ongoing temperatures of these three C/S babies, we found that their temperatures were lower than 36.5 with their initial assessment right after the OB brought them to the baby warmer. It took extra care and warming to get the temperatures back up to an optimal range.

We believe that this initial cooling from delayed cord clamping then set these SGA babies on an unstable, stressed course for their glucose levels over the next hours. The bigger babies can handle the delayed cord clamping and being cooler during the time, and many had initial temperatures that were in normal range. None of these larger babies had blood sugar issues.

Whether or not these SGA babies would have had the same post-partum course without delayed cord clamping is still a question.

What was the biggest barrier to making the change? |We did not experience any big barriers; we just have to consider SGA babies to NOT be appropriate for delayed cord clamping.

Added two cotton huck towels to the OR C/S bundle for the OBs to use to dry and cover the babies during delayed cord clamping. We requested warm sterile baby flannels for this, but this cannot be done.

We will continue to monitor to see if either of these changes make a positive difference.

If you have data or other evidence that your change was successful, please provide the data.

No additional data; see above. OF NOTE: none of these 3 SGA babies needed phototherapy.

If you have one piece of advice for someone who wanted to make a similar change in their setting, what would you advise?